National Alert System for Critical Antimicrobial Resistances: CARAlert

What is CARAlert?

The National Alert System for Critical Antimicrobial Resistances (CARAlert) was established by the Australian Commission on Safety and Quality in Health Care (the Commission) in March 2016 as part of the Antimicrobial Use and Resistance in Australia (AURA) Surveillance System. CARAlert collects surveillance data on nationally agreed priority organisms with critical resistance to last-line antimicrobial agents. Reports are produced and updated regularly and are accessible on this page.

Why did the Commission establish CARAlert?

The Commission established CARAlert to complement the existing processes for confirming CARs and to develop a system to provide more timely advice to state and territory health authorities on the occurrence of CARs in their hospitals and nationally.

While some data on CARs are captured through existing surveillance programs, the CARAlert system is the first nationally coordinated system that supports communication of information on confirmed CARs and potential CAR outbreaks as close as possible to the time of confirmation.

How does CARAlert work?

The CARAlert system is based on routine processes and practices used by pathology laboratories for identifying a potential critically resistant isolate and referring that isolate to a confirming laboratory with the capacity to confirm the CAR.

Public and private pathology laboratories that have the capacity to confirm CARs were identified via consultation with state and territory health authorities, the Public Health Laboratory Network and the Australian Group on Antimicrobial Resistance. These confirming laboratories have agreed to report confirmed CARs to CARAlert via a specially developed secure web portal, in addition to their routine processes.

The routine reporting practice is for the confirming laboratory to advise the originating laboratory of the result. The originating laboratory subsequently notifies the clinician who referred the specimen that a CAR has been confirmed.

The CARAlert system ensures that the information on confirmed CARs is also reported to state and territory health authorities and the Australian Government Department of Health on a weekly basis.

What information is provided to health authorities?

Information that could be used to identify a patient is not entered into CARAlert.

All health authorities are provided with information regarding the state or territory where the CAR isolate originated, the confirmation date and whether the patient who had the infection was admitted to hospital or was in the community at the time the specimen was collected.

Since October 2016 state and territory health authorities have also been able to access the name of the public hospital where the patient who had the infection was being cared for at the time the specimen was collected. This enables them to monitor the geographic distribution of CARs and to liaise with hospitals as appropriate, to confirm infection control action has been taken in the event of an outbreak.

Why is it important to monitor CARs?

Antimicrobial resistance is a serious health threat. The loss of effective antimicrobials through increased antimicrobial resistance will compromise Australia’s ability to fight infectious diseases and manage infectious complications common in vulnerable patients such as those undergoing chemotherapy for cancer, dialysis for renal failure, and surgery. Documenting CARs and providing the information about their occurrence, in a timely manner, to those who have the capacity to intervene ensures that outbreaks can be contained and the efficacy of last-line antimicrobials is maintained for as long as possible.

Is confirmation of a CAR important for treatment of an infected patient?

No. Confirmation of a CAR may not occur until some time after the infected patient has been treated and/or discharged from hospital. The occurrence of possible CARs in an individual patient is communicated to treating clinicians before a CAR is confirmed, so that appropriate treatment and/or infection control measures can be initiated.

The role of CARAlert is to monitor trends in the development of antimicrobial resistance in Australia in near realtime, for timely identification of clusters of infections and outbreaks, and for implementation and review of infection control strategies in the event of an outbreak.

The laboratory that performs the initial antimicrobial test (the originating laboratory) will, in accordance with usual processes, have advised the treating doctor, and infection control staff where appropriate, of the antimicrobial susceptibility profile of the isolate to enable timely and appropriate treatment to be prescribed for the infected patient.

Are private hospitals included in CARAlert?

The laboratories that provide pathology services to private hospitals issue reports on the confirmation of CARs in the same way as occurs for public hospitals.

What has been learned from reports of confirmed CARs since CARAlert commenced?

Since December 2016 azithromycin non-susceptible Neisseria gonorrhoeae have been the most frequently reported CAR of all CAR types. The next most frequently reported CAR were Carbapenemase-resistant Enterobacteriaceae (CPE), either alone or in combination with ribosomal methyltransferases (RMT).

The majority of CARs are reported from the three most populous states – New South Wales, Victoria and Queensland.

The IMP-type carbapenemase (mainly IMP-4) is now endemic on the eastern seaboard of Australia in several species of Enterobacteriaceae, particularly E. cloacae; this means that it is difficult to eliminate, and rigorous control measures are essential. There is no evidence that other carbapenemases have become established in Australia to date.

The frequency of reporting of azithromycin non-susceptible N. gonorrhoeae has increased over the last two years. This has occurred in the context of a significant increase in notifications of N. gonorrhoeae; and a decline in the proportion of isolates with elevated minimum inhibitory concentration values to ceftriaxone in Australia. There were variations in numbers and time of reporting between and within states and territories during the reporting period.

The outbreak was largely confined to a single facility, and was controlled within two months. Queensland Health hospitals have strategies in place to ensure early detection of any future CPE cases, and control and prevention of transmission.

Which hospitals have the highest number of CARs?

The number of CARs reported nationally is relatively small compared with the number of admissions to hospitals.

Hospital-level data have only been collected and available to state and territory health authorities since October 2016. No meaningful trends are available at this point.

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The Therapeutic Goods Administration (TGA) considers there is a lack of adequate scientific evidence for it to be satisfied that the risks to patients associated with the use of single incision mini‐slings for the treatment of SUI outweigh their benefits. These products have been removed from the Australian Register of Therapeutic Goods (ARTG)

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

In the short-term there are similar success rates for retropublic and transobturator

A

Obturator tapes slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.

A

However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.

B

Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen

C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

In the short‐term there are similar success rates for retropubic and transobturator mid urethral slings

A

Obturator tapes are slightly quicker, with less blood loss, bladder perforation and voiding dysfunction difficulties. Most of these differences were small and the complications are readily able to be managed.

A

However in the medium term (>5 years) the reoperation for recurrent SUI greater in obturator group and a small number developed groin pain (3-4%) that is difficult to treat.

B

Retropubic considered as the preferred procedure with transobturator reserved for those patients with a hostile abdomen

C

* Grades of Recommendation

This pathway is adapted from UroGynaecological Society of Australasia (UGSA) Surgical treatment of SUI pathway (2016)

Similar success rates compared to MUS with longer operating time and possibly higher voiding dysfunction; fascial sling has lower rates of chronic pelvic pain, no risk of erosion or extrusion, and higher rates of post‐operative morbidity